Methods—A cohort of 2324 patients who underwent coronary angiography from 4 independent centers was studied. A combination of ultra-performance liquid chromatography and quadrupole time-of-flight mass spectrometry (UPLC-Q/TOF-MS) in the negative ion mode was employed for untargeted analysis of metabolites in plasma. Significant differential metabolites were identified by cross comparisons with and within CAD types, including normal coronary artery (NCA), nonobstructvie coronary atherosclerosis (NOCA), stable angina (SA), unstable angina (UA), and acute myocardial infarction (AMI). A tandem LC-MS-based approach using isotope-labeled standard addition was subsequently performed for targeted analysis of the metabolic marker N-Acetyl-neuraminic acid (Neu5Ac). Finally, a functional metabolomics strategy was proposed to investigate the role of Neu5Ac, in the progression of CAD using in vitro and in vivo models.

Results—We identified a total of 36 differential metabolites, 35 of which were confirmed with reference compounds. Elevation of Neu5Ac was observed in plasma during CAD progression in Center 1 (p = 4.0e-64, n = 2019), and replicated in 3 independent Centers (n = 305). The increased level of Neu5Ac in plasma was confirmed by accurate targeted quantification. Mechanistically, Neu5Ac was able to trigger myocardial injury in vitro and in vivo by activation of Rho-ROCK signaling pathway through binding to RhoA and Cdc42, but not Rac1. Silencing neuraminidase-1, the enzyme that regulates Neu5Ac generation, ameliorated oxygen-glucose deprivation-induced injury in cardiomyocytes and ligation/isoprenaline-induced myocardial ischemia injury in rats. Pharmacological inhibition of neuraminidase by anti-influenza drugs, oseltamivir and zanamivir, also protected cardiomyocytes and the heart from myocardial injury.

Conclusions—Functional metabolomics identified a key role for Neu5Ac in AMI, and targeting neuraminidase-1 may represent an unrecognized therapeutic intervention for CAD.